A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Measure the client's vital signs before the client walks.

Determine if the client needs to have a gait belt applied.

Report the onset of any dizziness or lightheadedness.

Instruct the client about signs of orthostatic hypotension.

Offer to assist the client to void prior to walking in the hall.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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Correct Answer is A

Explanation

Choice A reason: Using a spacer allows time for the client to inhale the entire dispensed dose, ensuring that the medication is delivered effectively to the lungs.

Choice B reason: While a spacer may reduce the risk of oral thrush, it is not specifically intended to prevent mouth infections.

Choice C reason: A spacer does not slow the entry of medication into the lungs; it helps to deliver the medication more effectively.

Choice D reason: While using a spacer can increase the effectiveness of the medication, the primary reason is that it allows the client to inhale the entire dose properly.

A. Assess the client's ability to communicate with the other staff members. B. Arrange a meeting with the family to discuss the client's situation. C. Administer the client's antidepressant medication as prescribed. D. Establish a structured routine for the client to follow.

Correct Answer is D

Explanation

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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